BSN 2B GROUP 5

SOAPIE CHARTING

DATE & TIME NURSE’S NOTES

03-07-2023 Patient admitted with chief complaint of sudden elevation of blood
7:00 AM pressure, conscious but appears weak and in discomfort.

S- > “Bigla na lang po nag blurred yung paningin ko at para din

akong nasisilaw” patient stated.
> (+) Headache
O - > AOG 28 weeks,
> BP: 160/90,
>grade II bipedal edema
>proteinruria

A- Decreased Cardiac Output related to increased systemic vascular

resistance as evidenced by elevated blood pressure and edema.
P - > Within1 hr of intervention the patient will have controlled
blood pressure at or below 160/90

03-07-2023  I - > Monitored vital signs, specifically blood pressure.

8:00 AM >Assessed for edema; noted location and determined degree of
pitting.
>Weighted patient regularly
>Assessed for vision disturbances and cognitive function.
> Elevate edematous extremities, and handle with care
>Auscultate heart and lungs; note rate and rhythm; administer
oxygen as necessary.
> Administered medication (hydralazine, magnesium sulfate,
8:30 AM
methyldopa as prescribed by the physician.
>Monitored fetal heart rate.
>Monitored labs and diagnostic test results.
> Advised the client to have frequent rest periods and limit
activity to conserve protein requirements.
> Advised the client to have frequent rest periods and limit
activity to conserve protein requirements.
9:00 AM
E - < after intervention, the goals were met and the patient have
controlled blood pressure at or below 160/90
 PATIENT EDUCATION
FORM

Name Area OPD

Inclusive
Year Level BSN 2B RLE Group 5 dates of
Rotation
Name of Mrs. PIH
Age 28 y/o Gender FEMALE
Patient
Date
Admitted 03-07-2023 Diagnosis Mild – Pre eclampsia

MAIN CONCEPT / TOPIC: LIFESTYLE MODIFICATION

Details of Patient Education Content:

 Encouraged to exercise to prevent preeclampsia

o moderate exercise during pregnancy is recommended
 Encouraged to avoid smoking
o Increases risk of placental abruption in addition to fetal growth restriction
 Encouraged to avoid alcohol
o Excessive consumption may cause or exacerbate maternal hypertension
and lead to congenital anomalies
 Taught that weight reduction is not recommended for management of chronic
hypertension in pregnancy
o It is advised that women with BMI ≥30 kg/m2 should not gain weight of
>6.8 kg
o BMI should be kept within the normal range prior to the next pregnancy in
women with previous preeclampsia
 Advised to limit salt intake in diet
 Oral calcium supplementation of 1.5-2.5 g/day in early pregnancy decreases
incidence of preeclampsia and hypertension among all women and also reduces
severe preeclamptic complication in pregnant women with low daily calcium
intake (<600 mg/day)

Patient’s Signature / Significant Other’s Signature

Date Signed
Date Submitted

Form No.: TSU-COS-SF-09 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1